Palliative Care in Lacombe

1. Palliative Care
in
Lacombe

2. Assignment 1
Poster Presentation
Analyze a Palliative Service
or Program in Your Community
Lisa Bailey
ID 1431907
October 10, 2012
Grant MacEwan University
Nurs 483 Conceptualizing Hospice and Palliative Care
Instructor: Gail Couch

3. Lacombe, Alberta
Canada
Population: 11, 710
Located in central Alberta

4. Palliative Care Services
Located in Lacombe 75 beds
Long Term Care Hospital and Care (43 of which are
Centre. private rooms)
Home Care
Serves City of
Care is provided
Lacombe and
in client’s home.
County of
Lacombe.
Lacombe Hospital Care is provided
and Care Centre in the hospital. 2 palliative care suites.
Information for this project was obtained through interviewing senior Registered Nurses that work in the above settings.

5. Disciplines providing care and their responsibilities
Long Term Care
❖ Family Physician: Assesses resident at least one time per week,
orders and/or discontinues medications and treatments,
communicates with family.
❖ Nursing: (Registered
Nurses
(RN),
Licensed
Practical
Nurses
and
(LPN),
Health
Care
Aides
(HCA):
All
work
as
a
team,
it
is
important
to
note
that
their
responsibilities
are
very
similar
in
this
setting.

6. Disciplines providing care and their responsibilities
Long Term Care(continued)
❖ RNs: Primary responsibilities are medication administration and communicating
with the family and physician. Assists with dressing changes, personal care,
transferring and repositioning of residents if needed.
❖ LPNs: Medication administration, dressing changes, personal care, transferring
and repositioning of residents and assists with feeding residents.
❖ HCAs: Provide personal care, transferring and repositioning of residents and assists
with feeding residents.

7. Disciplines providing care and their responsibilities
Long Term Care (continued)
❖ Dietary: Assesses residents swallowing and recommends
appropriate diet.
❖ Occupational Therapy: Assesses residents mobility and provide
equipment for special needs regarding wheelchairs,beds,
cushions, walking aids and special eating utensils. Please note, RN that
was interviewed stated that “physiotherapists do not see palliative patients very often in this setting”.
❖ Pharmacy: Assesses residents and their medications. Makes
recommendations for medication changes as needed.

8. Disciplines providing care and their responsibilities
Long Term Care (continued)
❖ Volunteers: Provide respite for families and spend time with the
residents that do not have family members present.
Volunteers often sit, visit, play games, and read to residents.
I
see
volunteers
as
a
vital
and
valuable
part
of
the
team.
I
have
seen
LTC
volunteers
providing
the
extra
special
care
that
the
residents
deserve.
Mellow
(2007)
explained
that“Volunteers
feel
the
importance
of
their
contribution
lies
in
doing
tasks
that
nurses
do
not
have
time
to
do,
such
as
listening
to
stories
patients
tell...”(p.
464).
Mellow, M. (2007). Hospital Volunteers and Carework. The Canadian Review of Sociology and Anthropology, 44(4), 451-467.

9. Palliative Care
in Lacombe
Strengths LTC
•Pharmacy and their input.
•Calm environment. Weaknesses
•Staff have developed a relationship with residents and •Cafeteria has limited hours (1100h -1300h).
their families.
•No family rooms.
•Death is expected in LTC (residents are admitted
knowing they will most likely die there) •Environment is not conducive
Brock & Foley and Teno, Bird & Mor (as cited in Ersek for caring for families.
& Wilson, 2003) found that “recent estimates suggest
that by 2040, 40% of deaths will occur in NHs” (p. 45).
•Team works very well together.
•Access to Lacombe Palliative Care Society.
•Access to Palliative Care Resource Nurse.
Ersek, M., & Wilson, S. (2003). The challenges and opportunities in providing end-of-life care in nursing homes.
Journal of Pa!iative Medicine, 6(1), 45-57.

10. Palliative care challenges in
❖
Lacombe LTC
Difficult to provide care and maintain privacy
and dignity in semi-private and multiple bed
rooms.
❖ Family dynamics and different opinions about
palliative care.
❖ Residents with out do not resuscitate (DNR)
orders and advance directives.
❖ Some lack of specialty palliative care education
and training with staff.
It is evident that the The Canadian Hospice Palliative Care
Association (2012) also sees education as an issue in LTC they
stated “Providing care at end-of life has become vital to LTC
practice, however, palliative care has not been incorporated
into the culture and self-perceived roles of LTC. Further,
homes are not equipped with some of the specialized
knowledge and skills and dedicated resources to provide
palliative care” (para. 1).
Canadian Hospice Palliative Care Association (2012). End-of-life care in long term care.
Ottawa, ON : Author. Retrieved October 6, 2012 from
http://www.chpca.net/projects-and-advocacy/eol-care-in-ltc.aspxwww.chpca.net

11. Ways to manage palliative care challenges
in Lacombe LTC
❖ Always pull curtains, move palliative resident to
private room if possible, take roommate(s) out
of room if possible. Be aware that others are
around and can hear you.
❖ It is important to remember that all LTC
facilities are different and this dictates how the
palliative patient is cared for.
❖ Be respectful and take into consideration all of
the family member’s opinions (even if they have
not been to visit the resident). This not a time
to judge, take this opportunity to listen, to
show empathy and to teach.

12. Ways to manage palliative care challenges
in Lacombe LTC (continued)
✴Engage in conversation about advance care planning and goals of care upon
admission with resident and their family. This is essential as many LTC
residents have chronic or life threatening illnesses. Paulus (2008) made a good
point when she said “...advance care planning and establishing goals of care are
essential because they enhance the control patients have over their care and
assure autonomy if the patient is unable to communicate their wishes or make
decisions at later stages of illness” (Establishing goals of care section, para. 3).
Having DNR orders prior to admission to a palliative care program is
controversial and at times an ethical dilemma. I believe that residents and
families need more education in this area, they need to be reassured that it
does not mean that the resident will not get any care or not be well looked
after. They also need to be informed what CPR and post CPR can be like.
Gordon’s studies (as cited in Gordon, 2006) supported this idea when he talked
about CPR in the frail elderly by stating “Families should be told by physicians
and other health care providers about limited benefits to be gained from
CPR” (p. 2).
Gordon, M. (2006) . Ethical and clinical issues in cardiopulmonary resuscitation (CPR) in the frail elderly with dementia: A Jewish perspective.
Journal of Ethics in Mental Health, 1(1), 1-4.
Paulos, S. (2008). Pa!iative care: An ethical obligation. Retrieved from Santa Clara University, Markkula Center for applied ethics
website: http://www.scu.edu/ethics/practicing/focusareas/medical/palliative.html

13. Ways to manage palliative care challenges
in Lacombe LTC (continued)
✴ Encourage and inspire
staff to obtain more
knowledge and skills in
palliative care.
✴ Provide education
opportunities for all staff.
★ Ersek, Grant & Krayhill (2005) found that educating nursing staff in
end-of-life care in nursing homes improved patient outcomes (p. 557).
Ersek, M., Grant, M., & Kraybill, B. (2005). Enhancing end-of-life care in nursing homes: Palliative care
educational resource team (PERT) program. Journal of Pa!iative Medicine, 8(3), 556-566)

14. Palliative Home Care
The Canadian Hospice Palliative Care Association (2006) states in The Pan-Canadian gold standard for palliative home care that:
Canadians who chose to spend their final days at home typically
receive a signifiant amount of their care from family caregivers supported by members of the
interdisciplinary health care team (e.g., personal support workers, nurses, physician, pharmacists,
volunteers, depending on their hospice palliative care needs. (p. 8)
Canadian Hospice Palliative Association. (2006). The Pan-Canadian
gold standard for pa!iative home care. Ottawa, ON: Author.
Retrieved on October 8, 2012, from
http:// www.cdnhomecare.ca/media.php?mid=2394

15. Registered Nurse: Licensed Practical Nurse:
•Client assessment. •Personal care.
•Responsible for symptom management. •Dressing changes.
•Medication administration. •Psychosocial support to client and family.
•Infusion pump changes and adjustments. •Patient assessment, report assessment
•Development of nursing care plans. to registered nurse.
•Psychosocial support to client and family.
Disciplines providing care and
their responsibilities
Home Care
Mental Health Counsellor: Health Care Aide:
•Assessment of client and family. •Personal care.
•Counselling. •Respite care.
•Bereavement counselling after death. •Psychosocial support to client and family.

16. Volunteer:
•Respite care.
•Psychosocial support to client and family.
•Variety of responsibilities depending on what the patient and family
need (make meals, sit with client, visit with client, play games with
client, read to client).
Disciplines providing care and
•Swallowing assessments.
Dietician:
their responsibilities
•Gives family tips for providing highest
protein and calorie diet with
smallest volume.
Home Care
(continued)
Bruera (1997) studied nutrition and palliative care and
recognized that “Nutritional counselling should be based
on eating high calorie meals of small portions that are
pleasant for the patient” (p. 1222).
Occupational Therapist and Physiotherapist:
•Assessment of client’s mobility and transfers.
•Client and family teaching regarding safe transfers and
repositioning in bed.
•Supply equipment (walker, air mattresses, roho cushions etc.).
Bruera, E. (1997). ABC of palliative care: Anorexia, cachexia and nutrition. British Medical Journal, 315(7117), 1219-1222.

17. Palliative Home Care in
Lacombe
Strengths:
• Staff is highly dedicated and educated with a high sense of professionalism.
• Most clients are able to stay at home. This is becoming very common and desirable for many. It is evident
that in the last ten years there has been a shift from palliative care being institutional based to home based
( Peters & Sellick, 2006, p. 531). There are many reasons for this, Hudson (2003) found the “benefits of
palliative care at home include a sense of normality, choice, and comfort” (p. S36).
• Access to Lacombe Palliative Care Society.
• Access to Palliative Care Resource Nurse.
Hudson, P. (2003). Home-based support for palliative care families: Challenges and recommendations. Medical Journal of Australia, 179(6), S35-S37.
Peters, L., & Sellick, K. (2006). Quality of life of cancer patients receiving inpatient and home-based palliative care.
Journal of Advanced Nursing, 53(5), 524-533.

18. Palliative Home Care in
Lacombe (continued)
Weaknesses:
• Lack of Alberta Health Services funds to provide more
personal care, resources, and respite care.
• Decreased staff on evenings and nights (RN on call) LPNs
and HCAs available at times.

19. Challenges in Palliative Home Care in Lacombe
Some palliative care issues
and emergencies can make
At times client’s care needs
it difficult for the client
exceed the funds available
and family to be at home
for
(e.g., hemorrhage, spinal
palliative home care.
cord compression, drug
toxicity, and seizures).

20. Ways to manage challenges of Palliative Home Care in Lacombe
Seek out volunteers, friends, family, churches and social organizations to help supply resources to keep patient
at home (provide care, equipment, and funds).
Utilize Lacombe Palliative Care Society.
Provide education to families about palliative issues and emergencies.
Provide psychosocial support.
Ensure staff is available for emergencies.
Contact and consult Palliative Care Resource Nurse if needed.
If needed, allow client and family to say that they do not feel comfortable being at home anymore (they need
to know that this is ok). Stenekes and Streeter (2011) acknowledged that “Families often experience mixed
emotions about death at home, especially when: the person is unconscious and no longer able to respond to
family members; they realize that they many not be comfortable living in the home after a death” (p. 5).
Stenekes, S., & Streeter, L. (2011). Considerations for a home death. Canadian Virtual Hospice, 1-5. Retrieved October 8, 2012, from http://
www.virtualhospice.ca/Html2PdfHandler.ashx?vlink=en_US-Main%20Site%20Navigation-Home-Topics-Topics-Decisions-Considerations%20for
%20a%20Home%20Death

21. Hospital Palliative Care in Lacombe

22. Disciplines providing care and their responsibilities
Hospital Palliative Care
Nursing (Team):
RN: Assessments, medication
administration, personal care, psychosocial
support to patient and family, patient and family Family Physician:
teaching.
Daily rounds.
Dietician:
LPN: Assessments, medication Rotation of on call in ER.
Assessment of patient.
Nutritional assessments.
Dietary suggestions- changes in texture,
administration, personal care, psychosocial Medication and treatment orders. catered diets.
support to patient and family. Discussion and meetings with patients and families.
HCA: Personal care, psychosocial support
to patient and family.
Occupational Therapist (OT) and
Physiotherapist (PT):
(Often work together)
Pharmacist: PT: Depends on what stage of disease patient is in.
Assessment related to mobility.
Speech Pathologist:
Assessments related to medications.
Suggestions related to positioning and mobility. Swallowing assessments.
Medication suggestions.
Suggestions for eating and swallowing.
Medication teaching to patients and families.
OT: Assessments related to ADL’s and mobility.
Suggestions for positioning and mobility.
Supplies special chairs, cushions and utensils.
Families and staff provide care and volunteers are not used as much in this setting.

23. Hospital palliative care in Lacombe
Strengths:
Two private rooms and family
suites.
Rooms equipped with
kitchenettes.
Rooms have access to courtyard.
Some permanent staff (work
palliative care only), continuity of
care.
Well educated senior staff (invest
in continuing education).

24. Hospital palliative care in Lacombe
Weaknesses:
High staff turn over in the last 3-4 years (new staff
have not been as focused on and dedicated to
palliative care). This can be very difficult on staff.
Investments in new staff training and support can
help with retention. The results from Ablett and
Jones’s (2007) study suggested “implications for staff
training and support in that the factors that promote
resilience, particularly hardiness and a strong sense of
coherence, could be developed through staff training
packages” (p. 739).
No dedicated palliative physician of their own (rely
on family physicians and palliative physician consults
from Red Deer (30 km) and Rimbey (48.5 km).
Ablett, J., & Jones, R. (2007). Resilience and well-being in palliative care staff: A qualitative study of hospice
nurses’ experience of work. Psychooncology, 16(8), 733-740.

25. ❖ Care is in hospital which
Palliative care has a variety of patients on
same unit.
challenges in ❖ High acuity at times,
decreased time available
Lacombe for palliative patients.
Hospital ❖ Lack of funds from
Alberta Health Services
for palliative care services.

26. ❖ Be aware and sensitive of the different
How to manage patients and families on the unit.
❖ Create a relaxed and calm environment as
palliative care possible.
challenges in ❖ Contact government and AHS officials,
make them aware of
the need for more funds allocated to
Lacombe palliative care services.
❖ Utilize local social organizations,
Hospital volunteers and churches to help with
funding and resource issues.
❖Utilize Lacombe Palliative Care Society.

27. It is important to highlight two exceptional resources
that all
three settings have in common.

28. Lacombe Palliative Care Society
Mandate: To provide support and education to end-of -life care.
Funds for staff continuing education.
Hosts annual dinner and speaker every year during National Hospice Palliative Care Week
Hosts other educational events.
Keep palliative suites stocked (coffee, teas etc.).
Renovate palliative rooms and suites when needed.
Supply palliative volunteers.
“Volunteers often augment and enhance the range of EOL care services provided to terminally
ill individuals and their families” (Wilson et.al., 2005, p. 244).
Supply needed equipment for patients.
Will cover costs of medication if needed for palliative patients.
Wilson, D., Justice, C., Thomas, R., Sheps, S., MacAdam, M., & Brown, M. (2005). End-of-
life care volunteers: A systematic review of the literature. Health Services Management
Research 18(4), 244-257.

29. Access to Palliative Care Resource Nurse:
Provides consultation
Provides recommendations
Provides support to patients, families and staff.

30. Important to note
I think it is vital to share an unexpected outcome of the assignment.
None of the three palliative care staff that I interviewed talked about a chaplain,
member of clergy or minister being a part of the interdisciplinary team.
I found this very interesting because at my place of work they are an essential part of
the team. They provide meaningful religious and spiritual counselling to many
patients and their families. I concur with a research study that found the importance
of clergy to palliative care. It is an older study but still significant. In the 1990’s,
Flannelly, Weaver, Smith, & Oppenheimer (2003) found that chaplain and
community-based clergy were discussed and mentioned more frequently in three
palliative care journals than any other profession (p. 267). “The fact that clergy and
chaplains were mentioned most often in program descriptions gives some indication
of their integral role among hospice staff ” (Flannelly et al., 2003, p. 267).
I think it is very interesting that all three nurses either forgot (which I believe to be
the case) about this discipline or that they are not utilized in these settings.
This will require further research.
Flannelly, K., Weaver, A., Smith, W., & Oppenheimer, J. (2003). A systematic review on chaplains and
community-based clergy in three palliative care journals: 1990-1999. American Journal of Hospice
and Pa!iative Care, 20(4), 263-268.

31. Conclusion
In conclusion, I discovered that Lacombe offers a wide variety of exceptional
palliative care services. Each setting is unique in the way it delivers palliative
care. It is interesting how they all refer to the “patient” differently. Depending
on the setting, you be looking after a resident, a client or a patient. To gain a
full understanding of the palliative care services available, it is crucial to also
understand the similarities between the settings.
They all aim to provide excellent, holistic palliative care, to promote comfort
and prevent suffering in the dying. The Canadian Hospice Palliative Care
Association (2012) state “All Canadians have the right to die with dignity, free of
pain, surrounded by their loved ones, in the setting of their choice” (p. 12).
Canadian Hospice Palliative Care Association. (2012). Fact sheet: Hospice pa!iative care in Canada. Ottawa, ON: Author.

32. References
Ablett, J., & Jones, R. (2007). Resilience and well-being in palliative care staff: A
qualitative study of hospice nurses’ experience of work. Psychooncology, 16(8)
733-740.
Bruera, E. (1997). ABC of palliative care: Anorexia, cachexia, and nutrition. British
Medical Journal, 315(7117), 1219-1222.
Canadian Hospice Palliative Care Association. (2006). The Pan-Canadian gold
standard for palliative home care. Ottawa, ON: Author. Retrieved on October 8,
2012, from http://www.cdnhomecare.ca/media.php?mid=2394
Canadian Hospice Palliative Care Association. (2012). Fact sheet: Hospice palliative
care in Canada. Ottawa, ON: Author.
Canadian Hospice Palliative Care Association. (2012). End-of-life-care in long term care.
Ottawa, ON: Author. Retrieved on October 6, 2012,
from http://www.chpca.net/projects-and-advocacy/eol-care-in-ltc.aspx
Ersek, M., Grant, M., & Miller, B. (2005). Enhancing end-of-life care in nursing homes:
Palliative care educational resource team (PERT) program. Journal of Palliative
Medicine, 8(3), 556-566.
Ersek, M., & Wilson, S. (2003). The challenges and opportunities in providing end-of-life
care in nursing homes. Journal of Palliative Medicine, 6(1), 45-57.
Flannelly, K., Weaver, A., Smith, W., & Oppenheimer, J. (2003). A systematic review on
chaplains and community-based clergy in three palliative care journals:
1990-1999. American Journal of Hospice and Palliative Medicine, 20(4),
263-268.

33. References
Gordon, M. (2006). Ethical and clinical issues in cardiopulmonary resuscitation (CPR) in
the frail elderly with dementia: A Jewish perspective. Journal of Ethics in Mental
Health 1(1), 1-4.
Hudson, P. (2003). Home-based support for palliative care families: Challenges and
recommendations. Medical Journal of Australia, 179(6), S35-S37.
Mellow, M. (2007). Hospital volunteers and carework. The Canadian Review of
Sociology and Anthropology, 44(4), 451-467.
Paulus, S. (2008). Palliative care: An ethical obligation. Retrieved October 6, 2012, from
Santa Clara University, Markkula Canter for applied ethics
website http://www.scu.edu/ethics/practicing/focusareas/medical/palliative.html
Peters, L., & Sellick, K. (2006). Quality of life of cancer patients receiving inpatient and
home-based palliative care. Journal of Advanced Nursing, 53(5), 524-533.
Stenekes, S., & Streeter, L. (2011). Considerations for a home death. Canadian Virtual
Hospice, 1-5. Retrieved on October 8, 2012,
from http://www.virtualhospice.ca/en_US/Main+Site+Navigation/Home/Topics/Topics/Decisions/Considerations+for+a+Home
+Death.aspx
Wilson, D., Justice, C., Thomas, R., Sheps, S., MacAdam, M., & Brown, M. (2005). End-of-
life care volunteers: A systematic review of literature. Health Services
Management Research 18(4), 244-257.